374604128-2-27-2026-18-AS-JSRS-DRPT67-20260227132640

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604128
Report Date: 02/27/2026
Date Signed: 02/27/2026 01:26:51 PM

Document Has Been Signed on 02/27/2026 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	MOUNTAIN SHADOWS THERAPEUTIC DAY PROGRAM		FACILITY NUMBER:	374604128
ADMINISTRATOR/ DIRECTOR:	MOORE, HEATHCLIFFE		FACILITY TYPE:	775
ADDRESS:	970 LOS VALLECITOS BLVD #130		TELEPHONE:	(760) 743-3714
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92069
CAPACITY: 50		CENSUS: 6	DATE:	02/27/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Heathcliff Moore, Program Director		TIME VISIT/ INSPECTION COMPLETED:	01:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 02/27/2026, Licensing Program Analyst (LPA) Jacqueline Shaw-Ross made an unannounced visit to the facility to conduct an annual inspection. LPA was greeted and granted entry by Program Director Healthcliffe Moore, where LPA explained the purpose of the visit. The facility has a fire clearance for 25 ambulatory and 25 non-ambulatory adult clients and is approved for delayed egress. At the time of the visit there were twelve (12) staff and six (6) clients present. All staff were observed to have obtained criminal record clearance and to be associated to the facility. LPA conducted a tour of the interior and exterior of the facility. The facility was observed to be clean, and clutter free. The facility is a single level suite with staff office's, three (3) restrooms, an art room, computer lab, sensory room, Multipurpose room, kitchen and a garden, which contains shaded areas to sit as well as playground equipment. LPA observed several activities and games to promote socialization and physical fitness, including exercise equipment, a swing and a variety of board games/puzzles. LPA made observations throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. The facility is conducting emergency disaster drills every six months as required. Last drills were conducted on 11/06/2025. The annual fire inspection was last completed on 07/21/2025. The carbon monoxide and smoke detectors were observed to be operable. The facility has two (2) fire extinguishers that were last fully inspected on 02/04/2026. Hot water temperature tested at 108.9 which is within required temperature range. The cleaning solutions and disinfectants were observed in a locked supply closet and were in accessible to clients. The medications are inaccessible also observed to be stored in a locked medication cart. Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Jacqueline Shaw Ross
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN SHADOWS THERAPEUTIC DAY PROGRAM	FACILITY NUMBER: 374604128
	VISIT DATE: 02/27/2026

NARRATIVE

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LPA reviewed three (3) client records. All required documents were observed to be complete and up to date..

LPA reviewed three (3) employee records for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator. All documents reviewed were current and complete. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current.

LPA allocated time to prepare this report for delivery.

Based on the information received, there were no deficiencies observed during today's visit. An exit interview was conducted where a copy of this report was discussed with and provided to Program Director Heathcliffe Moore.

NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Jacqueline Shaw Ross
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

LIC809 (FAS) - (06/04)

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